Blood pressure and angiotensin converting enzyme inhibitor use in hypertensive patients with chronic renal insufficiency

I read with great interest the article “Blood Pressure and Angiotensin Converting Enzyme Inhibitor Use in Hypertensive Patients with Chronic Renal Insufficiency” in the December 2001 issue of the American Journal of Hypertension. Dr. Chi-yuan and colleagues provide an excellent introduction to the fact that in the United States blood pressure (BP) control is suboptimal1 and that little is known regarding the control achieved in physician's practice among patients with chronic renal insufficiency. They also stress the underuse of angiotensin converting enzyme (ACE) inhibitors in this important population and the few studies done to correlate different antihypertensive regimens with the different levels of renal dysfunction. Although ACE inhibitors have been shown to have a greater effect in delaying renal failure,2,3 most of the studies have been done comparing ACE inhibitors with placebo.2,4 Only a few studies compared other antihypertensives with ACE inhibitors, and at least one showed a comparable renoprotective efficacy of the non-dihydropyridine calcium channel blockers with ACE inhibitors.5 Most of the studies had only one BP target, but a limit for lowest BP target was not established. It is unknown whether the beneficial effect can be equalized by other agents when the BP achieved are much lower.6,7 It is important to remember that other interventions such as a low sodium diet, diuretics, tight BP control, whatever treatment is used, also enhance the antiproteinuric response to ACE inhibitors.8